Patient and Insurance Information by 8Zx77Ab

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									                                            Patient and Insurance Information
          In order to provide you the best possible care, please complete this form. All information is strictly CONFIDENTAL.

Patient Contact Information:

 Name: _______________________________________ Date:_______________ Email:_______________________________________________
                                                                                   Your email with NOT be shared with 3rd parties and is used only for general office
                                                                                                             announcements and promotions.
 Address:_________________________________________________ City____________________________ State________ Zip_____________

 Telephone #: Home: _____________________________ Cell: ______________________________ Work:____________________________

 Age:__________ Birth date ___________________ Social Security:_________________________________ Number of Children:___________

 Occupation:_________________________________________________ Employer:_________________________________________________

 Marital Status:___________________ Spouse’s Name:___________________________ Spouse’s Occupation:__________________________

 Spouse’s Employer: ________________________________________ Spouse’s Health Status: ______________________________________

 Emergency Contact: _____________________________________________________ Phone: _______________________________________

 Referred By:  Belleville Area Independent  Yellow Pages  Drive-By  Another Patient: ______________________________________
                                              Other:________________________________

Current Complaints:

 Nature of injury:  Automobile*      Work      Other

 Please Describe: _______________________________________________________________________________________________________

 ______________________________________________________________________________________________________________________

 Date of injury: ____________________ Date symptoms appeared:___________________________

 Have you ever had the same condition?  No  Yes            If yes, when?_________________________________________________________

 Have you ever been under chiropractic care?  No  Yes

 If yes, please describe: __________________________________________________________________________________________________


Insurance Information:

 Do you have health insurance?  No  Yes Name of Insurance Company: ____________________________________________________

          * If an auto accident is the reason for your care please provide:

 Auto Insurance Company Name:____________________________________ Contact person: _______________________________________

 Phone: _____________________________________ Claim # :______________________________________________


 I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I
 understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand
 that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and
 payable.

 Patient’s signature: ___________________________________________________________________ Date:_____________________________

 Spouse’s or guardian’s signature: ______________________________________________________ Date: _____________________________
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                                             Patient Health Questionnaire-PHQ

Patient Name_______________________________________________ Date____________________

 1. Describe your symptoms                ____________________________________________________________________________________
                                          ____________________________________________________________________________________
  a. When did your symptoms start?        ____________________________________________________________________________________
  b. How did your symptoms begin?         ____________________________________________________________________________________
2. How often do you experience your symptoms? Indicate on the figures below where you have pain or other symptoms.
   Constantly (76-100% of the day)
   Frequently ( 51-75% of the day)
   Occasionally ( 26-50% of the day)
   Intermittently ( 0-25% of the day)
3. What describes the nature of your symptoms?
   Sharp             Burning
   Dull ache        Shooting
   Numb              Tingling
4. How are your symptoms changing?
   Getting Better
   Not Changing
   Getting Worse
5. During the past 4 weeks:                                       None                                                              Unbearable

  a. Indicate the average intensity of your symptoms                        
  b. How much has pain interfered with your normal work? (including both work outside the home, and housework)

                                    Not at all  A little bit  Moderately  Quite a bit  Extremely
6. During the past 4 weeks how much of the time has your condition interfered with your social activities?(visiting with friends, relatives, etc)

                  None of the time  A little of the time          Some of the time        Most of the time  All of the time
7. In general would you say your overall health right now is…

             Poor  Fair  Good  Very Good  Excellent
8. Who have you seen for your symptoms?  No one                Chiropractor  Medical doctor  Physical Therapist  Other
  a. What treatment did you receive and when? ____________________________________________________________________________

  b. What tests have you had for your symptoms          X-rays    date:____________           MRI                        date:_________

    and when were they performed?                     CT Scan     date:____________          Other__________________      date:_________

9. Have you had similar symptoms in the past?           Yes                                    No
 a. If you have received treatment in the past for      This office        Chiropractor    Medical Doctor  Physical Therapist  Other
   the same or similar symptoms, who did you see?
10. If you are not retired, a homemaker, or a student, what is your current work status?

                            Full-time  Part-time  Self-employed  Unemployed  Off work  Other
Patient Signature ____________________________________________________________
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                                    ACKNOWLEDGMENT OF RECEIPT OF
                                     NOTICE OF PRIVACY PRACTICES



By signing below, I am acknowledging that:
        I am either the patient or the patient’s personal representative;
        I have been provided Main Street Chiropractic’s Notice of Privacy Practices; and
        I understand that I may contact the person named in the Notice if I have questions about the content of the Notice.



         _____________________________________________________________                                        __________________
         Signature of patient or parent/legal guardian/legally responsible person                             Date


         ___________________________________________________________________________________________________
         Description of relationship to patient




                                                 To Be Completed By Staff
                               Complete all applicable parts- Please refer to instructions


Part 1. Complete if signature requested but not obtained:
Staff member sought but was unable to obtain an acknowledgement from the patient of the patient’s personal representative for the
following reason:

 Patient/personal representative refused to sign form
 Other____________________________________________________________________________________________________
        _____________________________________________________________________________________________________

Part 2. Complete if patient/personal representative unavailable to sing form on first date of service delivery:

 Form mailed/sent to patient/personal representative on ______________________.
                                                                               Date




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                                                       Terms of Acceptance

When a patient seeks CHIROPRACTIC HEALTH CARE from my office and I accept them for such care, it is essential that we both
have the same objective and understanding.

CHIROPRACTIC care in this office has only one goal and that is to allow that body to function at its optimal capacity. While not
everyone will operate at 100%, we try and get as close to this as your body is capable of. Understanding this goal will prevent any
confusion or disappointment in our care.

Adjustment is a specific application of forces to facilitate the body’s correction of a vertebral subluxation.

Health is a state of optimal physical, mental, and social well-being, not merely the absence of a disease or infirmity.

Whole Food Supplements are made from nutrients in their natural, whole food state. They are not artificially produced as many OTC
supplements are.

Therapies such as heat/cold and traction are used to support the correction of the subluxation.

I do not offer to diagnose or treat any disease or condition other than vertebral subluxation. We locate the subluxated area(s) by
palpation, observation, orthopedic testing, nutritional system survey, and dermathermagraph readings. Once a subluxation is located, a
specific adjustment is given to aid in correction. We support these adjustments with whole food supplements, heat/cold, traction, other
therapies, home exercise, and other home care as recommended by our office.

Regardless of what a disease or pathological condition is called, other than subluxation, I do not offer or treat it or give advice regarding
treatment prescribed by others. My ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the body’s innate wisdom and
self correction.

Note: Please be aware that as with all forms of health care, chiropractic care as provided by this office has some risk. Even taking
something as simple as an aspirin can have detrimental effects on your health.

You may experience an increase in symptoms after an adjustment. This is usually very minor and temporary.

It is important that you communicate any concerns you have about your chiropractic care to this office. Any changes in your health that
concern you while under my care should be reported to this office immediately.

By signing below you are agreeing to the chiropractic care provided by my office and understand the objectives of the chiropractic care
offered.

Signature_________________________________________________________________________ Date: ___________________



                      Main Street Chiropractic of Belleville
                                     177 Main Street                                 Belleville, MI 48111
                                     (734)699-6600                                   Fax (734)699-6600
                             www.ourchiropractor.net                               chiro.mainstreet@att.net




                                                    Our Mission:
           "Uncompromising Commitment to Excellent, Compassionate, and Affordable Chiropractic Health Care".


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